As Republicans in Washington prepare to grill Health and Human Services Secretary Kathleen Sebelius on Wednesday over problems a broken website is creating for accessing Obamacare, their fellow party members in a dozen-and-a-half states have added complications for people trying to access those benefits through alternate means.
"Even as we improve the website, remember that the website isn't the only way to apply for coverage under these new plans," President Obama said in his weekly address Saturday, noting that applicants could use the phone or apply "in person with a specially trained navigator." The Affordable Care Act provided $67 million in federal grant money that went to local community groups to hire "navigators," whose job it is to help applicants through the process of applying for insurance.
But whether by fees, background checks, tests, extra training, certifications, threats of civil penalties, or delays, Republican legislatures and officials in at least 17 states across the country have thrown up all manner of bureaucratic roadblocks in front of the program.
The officials say the regulations are necessary to protect consumers and their personal information, but health care reform advocates say the regulations, adopted only in states controlled by Republicans, are just part of a multipronged campaign to obstruct the implementation of the Affordable Care Act at every turn.
In Georgia, Insurance Commissioner Ralph Hudgens boasted in a speech two months ago about a new state law that requires navigators to be licensed by his office. "Let me tell you what we're doing: Everything in our power to be an obstructionist," Hudgens said to cheers.
Amanda Ptashkin, the outreach and advocacy director for Georgians for a Healthy Future and a navigator herself, says she and other navigators had to go through a time-consuming process to get certified, first by the federal government, which requires 20 hours of training, and then by the state. The state's regulations required fingerprints, passing a background check, an affidavit of citizenship, getting a driver's license photo taken, paying a $50 fee, more training, taking a test, and waiting. When the exchanges opened on Oct. 1, only four or five navigators in the state had made it through the process. Almost a month later, they're up to 45 and things are working more or less smoothly, but it's difficult to coordinate efforts in the absence of state involvement. "It's unfortunate that we don't have leadership on the state level to help inform consumers," Ptashkin said.
To pro-Obamacare advocates like Ethan Rome, the executive director of Health Care for America Now, attacking the administration over problems with HealthCare.gov while also obstructing the work of the navigators in the states is "jaw-dropping, turbo-charged hypocrisy." "These people who say they want to fix the website aren't actually interested in helping people take advantage of the benefits of the ACA," Rome says.
"If you're one of these congressional Republicans, and you care deeply about how the website functions, here's my question: How many small businesses did you help get a tax credit? Because if the answer is zero, then just go home and don't ever come back to Washington," Rome adds.
At least four health care groups from Ohio to Texas have declined or returned hundreds of thousands of dollars in federal grant money in the face of state regulations. Meanwhile, navigators in Wisconsin say onerous regulations prevented them from getting to work sooner.
Some states like Indiana are making navigators pay as much as $175 for licensing, while Missouri and others states have passed laws limiting what kind of advice navigators can give to consumers, which advocate say has a chilling effect on their work. A lawsuit in Tennessee successfully challenged a similar law that authorized a $1,000 fine for violations. In Florida, navigators are barred from doing their work on the grounds of country health departments while state regulators held up licenses.
"Do I think it sinks outreach and enrollment? No. But do I think it's probably gotten a little slower, and do I think it's a big distraction and that it makes it harder to do their job, certainly yes," says Katie Keith, a former Georgetown health policy researcher who is now a consultant.
Before there were navigators, there was the Senior Health Insurance Assistance Program, which helps seniors navigate the Medicare Part D perscription-drug program. "It's what the navigator program was based on," says Keith, "and you just don't have these same kind of requirements on SHIPS as we see on navigators. And then you look at the list of states and you wonder, what's going on here?"
Still, navigators say they won't let the regulations stop them from doing their work. "Even given the pretty significant roadblocks and obstacles, the community groups that we've worked with have continued moving forward and doing what they need to do to become navigators," said Christine Barber, a senior policy analyst at Community Catalyst, a group based in Boston that supports health care advocates on the ground in 40 states.
"It's yet another obstacle that anti-ACA folks are putting in place to try to prevent this law from being a success," Barber says.
On top of the navigator restrictrions, 27 states, mostly controlled by Republicans, decided against setting up their own health care exchanges and instead left it to Washington, while 15 have have decided not to expanded Medicaid.
Jake Grindle, a navigator with Western Maine Community Action, says that while the website problems have made things "rockier than we imagined at the outset," the bigger problem is Republican Gov. Paul LePage's veto of a bill to expand Medicaid, which pushed about 25,000 Mainers into the coverage gap. "We're getting a lot of people being cut from Medicaid and expecting this to help them, but we're finding them to have incomes too low and to be in a gap that's really heartbreaking," says Grindle.